PTSD in Children and Adolescents: Equivalent Exposures, Distinct Diagnoses

One in four children living in the United States experiences a traumatic event before reaching adulthood.1 These distressing encounters, which include experiences from sexual abuse to natural disasters, affect the mental health of the individual as well as the overall wellbeing of the population. Because they are still in their formative years, children succumb more easily to negative experiences than adults. Childhood trauma is associated with depressed IQ, lower reading ability, increased school absences, and decreased graduation rates.1 Negative experiences can also cause post-traumatic stress disorder (PTSD) when trauma is severe or prolonged, or when children lack social support or necessary coping mechanisms. PTSD occurs with high levels of comorbidity, such that over 75% of those who suffer from PTSD struggle with additional mental health problems, including anxiety and depressive disorders.1 Studies show that three to 15% of girls and one to six percent of boys who have experienced trauma develop PTSD.2 Those who work in childcare and educational settings often lack sufficient awareness of and training for children’s mental health and their risks for developing PTSD. The profound negative effects of this mental health condition should, however, concern schools, especially after large-scale traumatic events.

The term “PTSD” may conjure images of returning veterans, war-torn countries, and extreme violence, all of which involve an adult male exposed to unimaginable tragedies overseas. Such cases certainly do exist, but we must also consider how PTSD affects traditionally neglected populations that also face various types of violence. These typically neglected populations include women and children. Recent research has shown, however, that the upsetting events that cause PTSD do not always inspire the same amount of awe and fear secondhand. Unaffected populations may not appreciate how a seemingly typical occurrence may cause equal damage, especially within more vulnerable populations. Natural disasters, motor vehicle crashes, and the suicide of a close friend all elicit stress responses severe enough to cause PTSD. No direct correlation exists between the “severity” of a trauma and the reaction that follows, since many other factors affect the stress response of each individual. In fact, accounts of firsthand trauma have the power to cause PTSD. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) requires that, in order to receive a diagnosis of PTSD, the patient (1) directly experiences the event; (2) witnesses the event; (3) learns that a close friend or family member has experienced a traumatic event; or (4) experiences repeated or extreme exposure to aversive details of the traumatic event.3

Although men experience more trauma in their lifetimes than women, the latter, perhaps surprisingly, are more likely to develop PTSD. In addition, in the United States, five percent of adolescents have met criteria for PTSD in their lifetimes, even though they may not have experienced the horrors of war.4 Children and adolescents thus comprise an invisible population of PTSD sufferers, overlooked not only by the health care system, but also by groups such as the education system that were designed to help them succeed. When the concept of PTSD first emerged in the 1980s, researchers believed that it could not apply to children and adolescents in the first place.5 The diagnosis of PTSD expanded to include children and adolescents only in 1987.6 Even within the populations of children and adolescents, however, responses to trauma vary. Children with a history of trauma in addition to the specific triggering experience develop PTSD at higher rates than their peers. Similarly, preexisting psychiatric disorders and a family history of psychopathology place children at higher risk for developing PTSD after a traumatic incident.3 Due to the developmental state of children, they are at higher risk of developing PTSD than adults. One study showed that, after the same exposure to trauma, 57% of adults developed PTSD, while 77% of children also received the diagnosis.7

A soldier suffering from PTSD. Source: Peter Murphy.

Children may experience PTSD differently than adults. The DSM-V has, for the first time, separated the experience of PTSD for those age six and under from the experience of adults.8 The inclusion of this subgroup marks an important step forward in the consideration and treatment of PTSD in children. Because verbal expression skills begin to emerge during the first six years of childhood, this subgroup requires diagnostic criteria that take into account their cognitive and verbal expression skills, for example, focusing more on behavior than on verbalization of the traumatic event.9 Parents and clinicians look for behavior such as disturbed sleep patterns, separation anxiety or clinging behavior, and conduct disturbances.7 Additionally, the diagnostic criteria must plan for increased sensitivity when working with children who may not yet be able to fully conceptualize the true extent of their experiences.9 Certain criteria, such as a “sense of a foreshortened future” included in the adult diagnosis also fail to distinguish traumatized children from their peers.9 The adult diagnostic criteria require that the re-experiencing symptoms manifest as recurrent, intrusive, and distressing; however, in young children, re-experiencing symptoms may manifest in a wide variety of emotions, including excitement. Thus, the DSM-V has removed the distress component of the diagnostic criteria for those ages six or younger.9 Children now only need to meet one criterion, rather than three, in order to receive a diagnosis of PTSD.

Children also exhibit unique symptoms when experiencing episodes of post-traumatic stress, such as “time skew” and “omen formation.”4 “Time skew” occurs when children attempt to narrate their trauma, but incorrectly sequence the events in their account. Children also often believe in the presence of warning signs that may have predicted the negative occurrence; as a result, they may become hyper-alert in an attempt to identify warning signs or omens of future traumatic events in order to avoid further suffering.4 Children suffering from PTSD may also reenact their trauma in drawings or verbalizations, or engage in post-traumatic play. In post-traumatic play, the child compulsively repeats an aspect of the trauma but cannot relieve her anxiety.4

We must demand that all childcare-related professions require ongoing training in PTSD and related disorders in children in order to gain a better understanding of the unique manifestations of PTSD in children. Parents often underreport PTSD in children, as well, since they do not realize that their children might experience as much or more distress than they.7 Educating parents, as well as childcare professionals, on the signs and symptoms of PTSD can increase awareness and reporting behavior, especially after large-scale traumatic events such as a school shooting or a natural disaster. This preparation ensures that children receive the mental health care they need in order to overcome adversity, thrive in school, and grow into healthy and productive members of their communities. Without such care, children may suffer from stunted developmental and educational growth in the face of overwhelming amounts of stress. Traumatized children are also at risk of developing personality changes, suicidal behaviors, and other psychiatric disturbances such as depression.5

As research on PTSD in children expands, innovative treatment options have begun to enter mainstream practice. Following large-scale traumatic events, schools serve as an ideal setting for interventions with children.10By establishing mental health interventions in schools, healthcare systems can increase the number of children who have access to mental health care. This practice will especially benefit locations where mental health care is not widely available, such as rural or low-income settings, or schools with underserved ethnic minority populations. Additionally, studies have found that children and adolescents spontaneously mention their trauma experience less than other age groups.10 School-based mental health care provides children with an opportunity to discuss and verbalize their trauma in a space that feels familiar and safe. School interventions can also leverage teachers as a resource, since educators may be particularly attuned to behavioral changes following traumatic events.

After Hurricane Katrina essentially demolished New Orleans and surrounding areas in August of 2005, researchers implemented and analyzed school-based mental health treatment in three New Orleans schools.10 They found that over 60% of students between grades four and eight exhibited symptoms of PTSD, a dramatic increase even after past history of trauma had been taken into account. The researchers introduced two different types of cognitive behavior therapy, the first-line treatment standard for PTSD, to students who had not already sought mental health care. They compared an innovative method called Cognitive Behavior Intervention for Trauma in Schools (CBITS) to the more traditional Trauma Focused Cognitive Behavior Therapy (TF-CBT).10 CBITS, conducted in schools in group settings with only children, focused more on the school setting, while TF-CBT took place in a clinic and parents were invited to attend counseling sessions.

The results of this study underline the important role that mental health interventions in schools may play in buffering the effects of stress and mitigating the symptoms of PTSD in children. In New Orleans schools, 98% of children assigned to CBITS successfully initiated treatment, while only 23% of those assigned to TF-CBT began treatment, despite efforts to provide free taxi service and childcare to those randomized to the TF-CBT group. While some children in each intervention group failed to complete the full intervention (10 sessions for CBITS and 12 sessions for TF-CBT), 91% of those randomized to the CBITS group completed the full intervention, while only 15% of those randomized to the TF-CBT group attended all twelve sessions. Children who attended counseling sessions within either intervention showed improved PTSD scores at six months, a statistic that demonstrates the importance of counseling more generally. CBITS, however, achieved stronger scores than TF-CBT.10

Child psychology experts revisited the importance of school-based mental health interventions after the Sandy Hook Elementary School shooting in December 2012, which took the lives of 20 children and six adults in Newtown, Connecticut. School shootings pose particular concern for both mental and physical health, because such extremely violent episodes disrupt the essential need for safety and security held by both children and adults.11 Following the shooting, the state government appointed an advisory committee to research and provide policy recommendations about issues such as firearm permits and registration, safe school designs, and mental health care.11 The March 2015 final report issued by this advisory committee called for schools to offer screening and referrals for mental and behavioral health services. The advisory committee also suggested that Connecticut public schools partner with pediatric healthcare providers to bolster the mental health resources offered by schools, and to increase the number of psychiatrists, social workers, and guidance counselors available at schools.11 Such efforts transform the school from the site of trauma to a site of healing, allowing children, teachers, and administrators to regain a sense of normalcy while still remembering the tragedy that occurred.

A memorial for the victims of the shooting at Sandy Hook Elementary School in December 2012. Source: Voice of America.

Another promising avenue of school-based mental health care recommended by the Sandy Hook Advisory Committee is the development of curricula focused on social and emotional learning (SEL). SEL has been proven to positively affect children’s development and academic performance.11 By teaching students how to name and identify feelings, SEL curricula help children and adolescents to cope with their difficult emotions. SEL curricula also help children develop positive social relationships, which can serve as buffers to future stress. This crucial preventive care could prove essential in the event of trauma and toxic stress, but school systems often neglect emotional learning and wellbeing in favor of rigorous and comprehensive academic curricula.11 Teachers and students, however, need such training to meet their emotional needs in order to prepare for upsetting and traumatic events.

While this essay examines research and policy recommendations for certain types of school-based intervention after two specific traumatic events, its results extend to other negative experiences. Initiation of peer group therapy following large-scale traumatic events may increase access to care and reduce stigma about mental health treatment. By placing these interventions within schools and allowing children to see the similar struggles of their peers, school-based health workers can foster a culture of mental health and wellbeing. The success of school-based mental health interventions should also open up conversations about training for teachers and administrators, since they may need to handle large-scale tragedies and to identify early signs of PTSD and other mental health issues in children through formal screening processes. Since symptoms of PTSD may not develop immediately after a traumatic event takes place, educators must monitor children in the weeks and months following a tragedy.1 Schools can better prepare for the onset of a large scale traumatic events by training teachers about the signs and symptoms of PTSD before such events take place. In contrast, educators will find it difficult to immediately implement such programs in the aftermath of a tragedy, since they will feel greatly affected by such events as well. The Sandy Hook Advisory Committee, for example, suggested ongoing professional development regarding strategies to bolster learning for grieving students and identification of children who may need additional mental health resources or referrals.

The consequences of a traumatic event extend far past its immediate aftermath, and post-traumatic stress disorder, as well as and other mental health problems, can affect anyone in the population, even if they have not experienced trauma firsthand. PTSD awareness must spread beyond veterans and war-related services. PTSD affects children and adolescents, women and men, military personnel and civilians. If we are to take the disease and its many consequences seriously, we must push for better integration of mental health care into primary care programs and school systems in order to ensure that everyone can easily receive treatment in the event of trauma. After all, there is no health without mental health.

Holly Robinson is a senior in Branford College double majoring in Russian and Anthropology. Contact her at holly.robinson@yale.edu.